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Background: The aim of this study was to evaluate and compare the accuracy of diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC) value, and time-intensity curve (TIC) type analysis derived from dynamic contrast-enhanced MR imaging (DCE-MRI) in differentiating benign from malignant adnexal masses., Materials and Methods: 47 patients with 56 adnexal masses (27 malignant and 29 benign) underwent DWI and DCE-MRI examinations, prior to surgery. DWI signal intensity, mean ADC value, and TIC type were determined for all the masses., Results: High signal intensity on DWI and type 3 TIC were helpful in differentiating benign from malignant adnexal masses (p<0.001). The mean ADC value was significantly lower in malignant adnexal masses (p<0.001). An ADC value<1.20?10-3 mm2/s may be the optimal cutoff for differentiating between benign and malignant tumors. The negative predictive value for low signal intensity on DWI, and type 1 TIC were 100%. The pairwise comparison among the receiver operating characteristic (ROC) curves showed that the area under the curve (AUC) of TIC was significantly larger than the AUCs of DWI and ADC (p<0.001 for comparison of TIC and DWI, p<0.02 for comparison of TIC and ADC value)., Conclusions: DWI, ADC value and TIC type derived from DCE-MRI are all sensitive and relatively specific methods for differentiating benign from malignant adnexal masses. By comparing these functional MR techniques, TIC was found to be more accurate than DWI and ADC.

Objective: To evaluate clinical outcomes associated with the resection of both endometrioma and posterior broad ligament (PBL) among women with PBL adhesion associated with endometrioma., Methods: Between January 2007 and December 2009 at the Villanova Hospital, Florence, Italy, a prospective trial was conducted on 99 consecutive patients with unilateral or bilateral endometrioma who underwent laparoscopic ovarian cystectomy by a stripping technique and homolateral PBL resection where PBL adhesion was associated with endometrioma. The prevalence of PBL adhesion and endometriosis, the association between PBL endometriosis and pain, and the recurrence of endometrioma and pain were evaluated. All data were analyzed with Prism software., Results: Among 124 endometriomas treated by concomitant PBL resection, the PBL was not affected by adhesions in only 2% of patients. PBL endometriosis was superficial in 36 (29.5%) and deep in 86 (70.5%) of the histologic preparations; deep endometriosis correlated with preoperative pain. At 1-year follow-up, endometrioma had recurred in 7 patients; the main symptom reported was mid-cycle pain (24 patients, 24%; P=0.0007)., Conclusion: Ovarian endometriosis was often (98%) associated with PBL endometriosis; deep endometriosis of PBL correlated with pain symptoms. Although PBL resection increased the incidence of mid-cycle pain, it was associated with low recurrence of endometrioma., (Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

The purpose of this investigation was to establish the prevalence and distribution of MR findings associated with pelvic endometriosis in patients with a MRI diagnosis of adenomyosis. Retrospective review of the pelvic MRI in 59 patients (age 32-54 years, mean 42 years) who met strict MRI criteria for adenomyosis was performed. T1 weighted fat saturated and T2 weighted images in these patients were reviewed for the presence or absence of T1 bright signal suggesting endometriosis in any of nine locations (uterine serosa, right and left ovary, right and left fallopian tube, right and left broad ligament, and right and left pelvic side wall). 20 (20/59) patients (34%), showed characteristic MRI features associated with endometriosis. A total of 54 sites of involvement were identified (uterine serosa n = 17, ovaries n = 14, broad ligaments n = 10, fallopian tubes n = 8, pelvic side walls n = 5) in 20 patients with an average of 2.7 sites per patient. Implants (n = 43) were more common than endometriomas (n = 11). Endometriomas occurred most often in the ovaries (ovaries n = 9, broad ligament n = 2) whereas implants were seen on all locations (uterine serosa n = 17, ovaries n = 5, broad ligaments n = 8, fallopian tubes n = 8, pelvic side walls n = 5). One third of patients with adenomyosis diagnosed by MRI also had MRI findings of endometriosis, with serosal implants being the most common finding. Imaging protocols should routinely include T1 weighted fat saturated imaging sequences in order to detect coexistent endometriosis in patents undergoing pelvic MRI for the diagnosis of adenomyosis.

Endometriosis corresponds to ectopic endometrial glands and stroma outside the uterine cavity. Clinical symptoms include dysmenorrhoea, dyspareunia, infertility, painful defecation or cyclic urinary symptoms. Pelvic ultrasound is the primary imaging modality to identify and differentiate locations to the ovary (endometriomas) and the bladder wall. Characteristic sonographic features of endometriomas are diffuse low-level internal echos, multilocularity and hyperchoic foci in the wall. Differential diagnoses include corpus luteum, teratoma, cystadenoma, fibroma, tubo-ovarian abscess and carcinoma. Repeated ultrasound is highly recommended for unilocular cysts with low-level internal echoes to differentiate functional corpus luteum from endometriomas. Posterior locations of endometriosis include utero-sacral ligaments, torus uterinus, vagina and recto-sigmoid. Sonographic and MRI features are discussed for each location. Although ultrasound is able to diagnose most locations, its limited sensitivity for posterior lesions does not allow management decision in all patients. MRI has shown high accuracies for both anterior and posterior endometriosis and enables complete lesion mapping before surgery. Posterior locations demonstrate abnormal T2-hypointense, nodules with occasional T1-hyperintense spots and are easier to identify when peristaltic inhibitors and intravenous contrast media are used. Anterior locations benefit from the possibility of MRI urography sequences within the same examination. Rare locations and possible transformation into malignancy are discussed.

Study Objective: To assess the results of complete surgical excision for patients with painful functional symptoms in a context of histologically proven deeply infiltrating endometriosis (DIE)., Design: Retrospective analysis (Canadian Task Force classification II-2)., Setting: University-affiliated hospital., Patients: One hundred thirty-two patients with pelvic pain symptoms and histologically proved DIE. The DIE lesions were classified according to surgical classification: uterosacral ligaments (USL), vagina, bladder, or intestine., Intervention: Complete surgical excision of DIE lesions., Measurements and Main Results: A retrospective analysis was made of medical, operative, and pathologic reports as well as of questionnaires mailed to patients. Efficiency of surgical excision was assessed according to two methods: objective evaluation (numerical rating scale) and subjective evaluation (patients were asked to classify the improvement after surgery with one of the following: excellent, satisfactory, slight, or no improvement). For each symptom, the mean scores according to the numerical rating scale were significantly lower postoperatively. The difference between the preoperative and postoperative scores was 5.2 points +/- 3.6 for dysmenorrhea, 4.6 points +/- 3.1 for deep dyspareunia, 4.4 points +/- 3.7 for painful defecation during menstruation, 4.9 +/- 3.2 for lower urinary tract symptoms during menses, and 4.6 points +/- 3.4 for noncyclic chronic pelvic pain. Comparable results were observed for patients in each group according to the surgical classification of their DIE lesions: USL (n = 78 patients); vagina (n = 25 patients); bladder (n = 13 patients); and intestine (n = 16 patients). Subjective evaluation showed that the improvement was considered to be excellent in 40.2% of women (53 patients), satisfactory in 42.4% (56 patients), slight in 14.4% (19 patients), and nonexistent in 3.0% (4 patients). The patients' characteristics (i.e., age, gravidity, parity, body mass index, preoperative medical treatment, follow-up after surgery, number and location of DIE lesions, revised American Fertility Society stage, associated endometrioma) did not differ significantly according to whether the improvement was considered to be excellent (Group A: 53 patients) or not (Group B: 79 patients). Among the infertile patients (n = 78; 59.1%), there was no difference in pain improvement if the patient was pregnant or not in the 42 women who achieved pregnancy after the surgery., Conclusion: Complete surgical excision of DIE lesions results in a statistically significant reduction in painful functional symptoms. These results are observed whatever the main location of DIE lesions. The patients' preoperative characteristics have no significant influence on the result.

Background: Nerve sparing is suggested for cancer surgery, but no experience is available for deep endometriosis. The aim of this study was to laparoscopically identify the pelvic nerves in the posterior pelvis., Methods: A total of 24 patients operated for deep endometriosis were considered. During surgery and on videotapes of the procedures, we evaluated single- or double-sided resection of the uterosacral ligaments and other structure's visualization of the inferior hypogastric and the splanchnic nerves. The most important objective criteria for resection of the nerves was urinary retention after surgery, which was compared to surgical resection on the videotapes., Results: Visualization of the inferior hypogastric nerves was possible in 20 of 22 patients (90.1%). Eight of the 24 patients had at least one inferior hypogastric nerve resected (33.3%). In seven patients (29.2%) resection of the uterosacral ligaments was bilateral, and in three of these the nerves were resected. Postoperatively, the median residual urine volume after the first spontaneous voiding was 40 ml (range, 20-400). Seven of eight patients (29.2%) with resection of the nerves had urinary retention and self-catheterization at discharge. The difference in urinary residuum after first voiding between patients undergoing self-catheterization and patients released without the catheter was significant ( p < 0.01). The median time to resume the voiding function in patients with self-catheterization was 18 days (range, 9-45)., Conclusions: Nerve visualization is possible by means of laparoscopic surgery for deep endometriosis in a high rate of patients. Careful technique is necessary, but the laparoscopic approach may help. Even single-sided radical dissection can induce important urinary retention.

Study Objective: To describe the histologic appearance of deep endometriosis infiltrating the uterosacral ligaments (USL)., Design: Retrospective analysis (Canadian Task Force classification II-2)., Setting: University-affiliated hospital., Patients: One hundred forty-nine women with pain due to endometriosis., Intervention: Resection of one or both USL., Measurements and Main Results: One hundred seventy-two USL were examined by histology after unilateral resection in 126 patients (84.6%) and bilateral resection in 23 (15.4%). Two-thirds of women (122, 70.9%) had a classic appearance of endometriosis. Lesions of myoproliferative endometriosis with a histologic appearance of so-called adenomyotic nodules were observed in 25 (14.5%). Associated fibrosis was most frequent in patients with positive compared with negative histology (85, 69.7% vs 18, 36.0%)., Conclusion: Anatomicopathologic lesions of deep endometriosis infiltrating the USL are heterogeneous. Adenomyotic nodules are not frequently observed.

Peritoneal endometriosis presenting as a tumor is very rare. A case of peritoneal endometriosis in the broad ligament presenting as a large tumor is reported. A 39-year-old woman had a solid and cystic tumor with many microcysts, measuring 17 x 13 x 3.5 cm, mainly located in the right posterior broad ligament. Histologically, the tumor consisted of many endometrial glands associated with various amounts of endometrial stroma. Neither the glands nor the stromal cells had cellular atypia. We diagnosed peritoneal endometriosis presenting as a tumor. Among the six cases (five previously reported cases and our case) of tumor-like endometriosis in the peritoneum, two cases (33%) had received tamoxifen therapy and four cases (67%) had cystic or solid and cystic tumor. Among them, the tumor size ranged from 3 to 17 cm in diameter, and our case was the largest. In conclusion, this case is rare, but it is important for pathologists to be aware of the phenomenon (that extensive peritoneal endometriosis produces a large tumor) in the histological diagnosis of a tumor in the peritoneum.

A review of 2 cases of 46,XY pure gonadal dysgenesis (Swyer's syndrome) is presented. In one, bilateral gonadoblastomas with dysgerminomas were found at the time of laparotomy for gonadal extirpation. The second case was of interest because of endometriosis on the mesosalpinx, an entity heretofore undescribed in pure gonadal dysgenesis.

The authors have reassessed the anatomic distribution of ectopic endometrium by the laparoscopic study of the location of implants, adhesions, and uterine position in 182 consecutive patients with infertility and endometriosis. The ovary was the most common site of implants with 54.9% having either unilateral or bilateral involvement. This was followed, in order of frequency, by the posterior broad ligament (35.2%), the anterior cul-de-sac (34.6%), the posterior cul-de-sac (34.0%), and the uterosacral ligament (28.0%). Adhesion formation followed the same anatomic distribution. No patients were noted to have endometriosis of the cervix and vagina. Endometriosis of the anterior compartment (anterior cul-de-sac, anterior broad ligament, and anterior uterine serosa) was significantly more common in patients with anterior uteri (40.7%) versus patients with posterior uteri (11.8%, P less than .0005). Exclusive anterior compartment disease was found only in patients with anterior uteri, and significantly more commonly in patients with severely anteflexed uteri (P less than .005). These data suggest that factors influencing implantation of retrograde menstrual debris include: the dependent pooling of peritoneal fluid as affected by uterine position; epithelial cell type at the site of implantation; unique ovarian susceptibility; route of entry; and mobility of the pelvic structures. The data support the Sampson hypothesis of retrograde menstruation as the primary model of development of endometriosis.